Dear Addy,
I know that the Open Enrollment Period for health insurance is right around the corner. As a person with a bleeding disorder, what should I look for in an insurance plan?
Signed,
Savvy Subscriber
Dear Subscriber,
The Open Enrollment Period is a time frame each year when health insurance plans or HMOs (health maintenance organizations) are required by law to accept applications from new plan enrollees regardless of their health history. This also is the time when you can choose to stay with your existing health plan if it is the right one for you. Generally, open enrollment is held once a year, typically in the fall (the exact dates will vary depending on where you get your insurance coverage: from your workplace, from an ACA Marketplace, etc.).
Scope of Coverage: When reviewing potential health insurance plans (and when considering whether to renew your existing plan), it is important to review all plan provisions carefully. You will want to closely read the “general provisions” (length of policy, types of providers you can see, term definitions), the “drug provision” (is your factor product, and any other drugs you need, covered by the plan), and the provisions that describe claims and the payment of claims. Federal law requires health plans to spell out all these terms, plus many others, in easily understood language.
After reviewing any potential plan, you should be able to answer the following questions. If you can’t, contact your company’s human resources department, your HTC social worker, or a Marketplace navigator if you are selecting a plan via the Marketplace.
- What is the overall deductible?
- Are there separate deductibles for specific services?
- What is the out-of-pocket limit on my expenses?
- What is not included in the out-of-pocket limit?
- Is there an overall annual limit on what the plan pays?
- Does the plan use a network of providers? Are my key providers (hematologist, specialty pharmacy, etc.) in-network? What do I pay for out-of-network care?
- Do I need a referral to see a specialist?
- Are there any services the plan doesn’t cover?
- Does the plan use a preferred drug list and, if so, will my product of choice be covered? Is my product covered under the pharmacy benefit or under the medical benefit?
Timing: If you get insurance through your job, check with your human resources department to find out when your company’s open enrollment period begins and ends. If you get your health insurance through the ACA Marketplace, please note that in most states the 2019 open enrollment period will run only from November 1, 2018, to December 15, 20178. For people with Medicare coverage, open enrollment runs from Oct. 15 – Dec. 7, annually. The open enrollment period for Medicaid is 365 days a year, available to those who need it, whenever that occurs.
Special Considerations for 2019 Plan Year: As you approach open enrollment this year, it is more crucial than ever that you carefully research your options and DO NOT simply auto-renew your existing insurance plan. Decisions made in Washington, DC, in the past year are having complicated effects on insurance costs, so you will have to take extra care to evaluate your options to pick the plan that offers you the best and most affordable coverage.
- Additional insurers are joining the ACA exchanges in many states. You may have new options for 2019 that you didn’t have last year.
- Premium subsidies for purchasers of ACA exchange plans will be lower in some states, higher in others, based on overall market conditions and on whether new insurers are entering the particular market. In order to avoid an increase in the share of the premium that you pay, you may have to switch plans.
- If you buy your insurance in the individual market AND you earn too much to be eligible for premium subsidies, you may want to broaden your search to include off-exchange insurance plans. Off-exchange plans have to meet ACA requirements for coverage, out-of-pocket exposure, etc., but may in some cases have lower premiums than ACA plans.
- But BEWARE – a new federal rule has expanded the availability of so-called “short-term, limited duration health plans.” These short-term plans do NOT provide adequate coverage for people with bleeding disorders. Short-term plans can turn you down based on your health condition, or refuse to cover your bleeding disorder, and typically don’t cover prescription drugs. You can learn more about the drawbacks of short-term plans here.
- Watch out for plan limits on your ability to make use of manufacturer co-pay assistance programs. “Accumulator adjuster programs” are new strategies that are starting to crop up in insurance plans. Under an accumulator adjuster program, the health plan accepts manufacturer-provided co-pay assistance but doesn’t credit that amount toward the patient’s overall deductible or out-of-pocket maximum. As this infographic illustrates, the use of an accumulator adjuster can create huge financial burdens for patients and their families, leaving them on the hook for out-of-pocket costs up to their yearly maximum. Unfortunately, it can be hard to spot whether your plan contains an accumulator adjuster, since these provisions appear under a variety of (sometimes misleading) names. Read carefully and keep pressing for answers.
A reliable resource for information on open enrollment for 2019/individual insurance plans can be found here and a detailed set of FAQs (including many in Spanish) can be found here. Please be an active participant as you consider your insurance options for 2019! And whether you choose to keep your current health insurance or to enroll in a new plan, READ YOUR POLICY. This is critical because the health insurance plan you choose will be yours for 12 months unless you have a qualifying life event that allows you to switch plans.
Sincerely,
Addy
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HFA frequently receives questions from the bleeding disorders community related to advocacy issues. The questions often impact the entire community. In an effort to reach the largest audience possible with our responses to these widely applicable questions, HFA developed “Dear Addy.” Questions submitted to this column are edited in order to protect privacy and should be considered educational only, not individual guidance.
